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A Step-by-Step Path to Medicare for All
Without Betting Everything on Day One
A new Yale study says single payer could save $1.04 trillion a year. Maryland has spent a decade proving that a large piece of that number is already real, without anyone abolishing private insurance. Put the two together, and the honest path forward isn't a single bill that has to work perfectly on day one — it's a sequence, where each step has to earn the next one.
Editorial · September 1, 2026
The Yale Study
The trillion-dollar number
In August 2026, researchers at the Yale School of Public Health, led by professor Alison Galvani, published an analysis projecting that a single-payer system modeled on the Medicare for All Act would cut U.S. national health spending from $5.28 trillion to $4.24 trillion a year — a reduction of $1.04 trillion, or nearly 20 percent — while extending coverage to everyone. The same model estimated the change would avert roughly 114,000 deaths annually, about half of them among people who already have insurance today.
That's an extraordinary claim, and it deserves an extraordinary amount of scrutiny before anyone treats it as settled. The study is a preprint, posted to medRxiv, not yet peer-reviewed. Its savings come from three big assumptions stacked on top of each other — each individually defensible, but together the most favorable version of every assumption at once.
Testing the claim. When more conservative versions of the same three assumptions are substituted — smaller drug-price concessions, provider rates set above today's Medicare floor rather than at it, less sweeping administrative consolidation — the trillion-dollar figure shrinks sharply, by most of the way. But it doesn't vanish. Under nearly any reasonable combination of assumptions, the same three levers — prices, provider rates, and paperwork — still produce real savings. That turns out to matter more than the headline number itself.
It's also exactly what the Congressional Budget Office concluded when it modeled five different illustrative single-payer designs in 2022: depending on how a plan sets provider payment rates and how much utilization increases once care is free at the point of service, national health spending could fall by as much as $700 billion or rise by as much as $300 billion — under the same basic label of “single payer.”
“The financing structure alone doesn't determine the outcome. The rules inside it do.”
The Maryland Model
What Maryland already proved
If the rules matter more than the label, the next question is which rules actually work — and there, we don't have to guess. Maryland has been running the experiment since 2014.
Maryland is the only state where every hospital is paid under a single, regulated rate structure, whoever the patient's insurer is. On top of that rate system, Maryland gives each hospital a global budget: a fixed, population-based revenue target for the year, adjusted for population growth, aging, and disease burden, rather than payment for each individual admission and procedure. Under ordinary fee-for-service billing, a hospital makes more money when it does more. Under a global budget, a hospital does better when its patients stay healthy enough to avoid the hospital altogether.
None of that required abolishing private insurance. It required changing what hospitals get paid for. CMS has taken notice — its new AHEAD model, combining hospital global budgets, primary-care investment, and multi-payer alignment, is explicitly built on Maryland's template, and Maryland itself is applying to move onto it. This isn't a theoretical proposal anymore. It's the most-tested piece of healthcare-financing reform in the country.
The Sequence
So what should replace the system?
Put Yale's stress-tested conclusion next to Maryland's decade of results, and the honest answer isn't “pass Medicare for All in one vote and hope.” It's a sequence — one where each step has to earn the next one, rather than a single bill that has to work perfectly on day one or not at all. It builds on the fuller reform model laid out in the updated appendix to Beyond Reform, but the sequence itself — and every figure behind it — is argued in full here. It runs in roughly this order:
- Fix the prices first. Move to national, all-payer rate-setting for hospitals and physicians — not simply imposing today's Medicare rates everywhere, but an independent process that sets rates based on real operating costs, regional wages, rural access, and teaching and trauma responsibilities. This is the single largest lever in every version of the model, Yale's and this one.
- Fix the incentive, not just the price. Extend Maryland-style global budgets to hospitals nationally, adjusted for the population each one actually serves. A hospital should never make more money because the people in its service area got sicker.
- Negotiate drug prices — but don't build the whole model on it. A national Drug Pricing Board, similar to what the VA already runs, should negotiate directly. Because drug savings are the most assumption-dependent part of every projection, the rest of the model has to work even if this piece delivers less than hoped.
- Standardize the paperwork. One claims form. One eligibility system. One set of billing codes. One sharply limited prior-authorization process. Insurers keep competing — on service, on networks, on care coordination — but not on which one can make the system hardest to navigate.
- Cover the people the current system already fails. A public plan — American Care — automatically covers the uninsured, Medicaid recipients, and ACA marketplace enrollees, with income-based cost sharing and zero cost at the point of care for the lowest-income Americans. This doesn't ask the roughly 155 million people with employer coverage to change anything.
- Then let everyone in, gradually. Individuals get the right to buy into American Care. Later, employers get the right to offer it. Nobody is forced to switch. If it delivers better care for less money, people migrate toward it on their own.
- Measure everything, and only expand what's working. If the public option consistently outperforms private insurance, it grows. If it doesn't, it gets fixed before it grows. Single payer stops being the starting assumption and becomes a possible outcome — one the system has to earn through results, not legislate through ideology.
Why the order matters
Notice what's missing from that list: a single moment where tens of millions of Americans with employer coverage wake up to find their insurance card replaced overnight. That moment is where every previous attempt at large-scale healthcare reform has taken its worst political and practical damage. Treating the transition itself as the central risk to be managed — not a footnote to be waved away — is the most important lesson sitting underneath both the Yale numbers and the Maryland results.
None of this requires anyone to first win an argument about the size of government. It requires fixing the prices, fixing the incentives, fixing the paperwork, covering the people currently being failed, and then letting the results decide what comes next.
Every figure above is sourced and linked where it's used. This piece builds on the fuller reform model laid out in the updated appendix to Beyond Reform, part of the broader Broken Promises Healthcare investigation into why American healthcare costs what it does and what the evidence says would actually fix it.